I _________________________________________________________________ do swear and depose as follows: 1. I am the owner of a well located in the _________ of the _______ of Sec. ____ Township _____S/N (Circle one.), Range ______ E/W (Circle one.), well permit no. ________, WDID no. (Only if decreed.) ____________. The well is permitted for _______ gpm/cfs (Circle one.), for ________________________________ uses. 2. I have been using the well identified above as the water supply for the following uses listed in Section 37-92-602 (1)(b) or (1)(e), C.R.S.: a. Ordinary household uses in ______(No.) single-family dwellings; b. The irrigation of ______(Area/ acres) of vegetation. c. The watering of domestic animals ____yes / ____ no. since prior to May 8, 1972. 3. Per historical considerations of drought and or rainfall, I will continue same uninterrupted usage of said well respective of. 4. In good faith I retain the right to continue into the future, as in the past, the handling of my own metering, measurements, and operation hereon. 5. I understand the Division Engineer seeks to abandon all but some water rights, and limit the decreed capacity to _____ gpm/cfs, associated with this well in the next decennial abandonment list pursuant to Section 37-92-401 (2)(b). 6. Please know that it is not my intention to abandon my right to use said well. 7. I hereby attest that it is my unequivocal intention to exercise my right to continue uninterrupted usage of said well, as I, owner of well, deem necessary. 8. Furthermore, I hereby demand that no entity, including state, county, city, town, township, or school district, shall encumber same usage of said well, for any and all successors-in-interest. ___________________________ _________________________ Print Name Affiant (Signature) _________________________________________________________________Address ___________________________________________________________City, State, Zip Subscribed and sworn to before me in the County of __________, State of ___________, This _________day of _____________, 200__________ ___________________________________________________ My commission expires:________________________ NOTARY PUBLIC
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